Disability Doc

13.28 Malignant neoplastic diseases treated by bone marrow or stem cell transplantation . (See 13.00L.)

A. Allogeneic transplantation. Consider under a disability until at least 12 months from the date of transplantation. Thereafter, evaluate any residual impairment(s) under the criteria for the affected body system.

OR

B. Autologous transplantation. Consider under a disability until at least 12 months from the date of the first treatment under the treatment plan that includes transplantation. Thereafter, evaluate any residual impairment(s) under the criteria for the affected body system.

Allogeneic transplantation – uses bone marrow stem cells or peripheral blood stem cells from someone else.

Autologous transplantation – uses the patient’s own bone marrow stem cells or peripheral blood stems cells.

“Bone marrow transplantation” refers to stem cells derived from bone marrow.

“Stem cell transplantation” refers to stem cells derived from peripheral blood.

Stem cells from bone marrow or peripheral blood are immature precursors of blood cells; and when they mature, form white blood cells (fight infection), red blood cells (carry oxygen), and platelets (help blood clot).

One reason bone marrow (stem cell) transplantation and (peripheral blood) stem cell transplantation are used in cancer treatment is to make it possible for patients to get very high doses of chemotherapy and/or radiation. This high-dose therapy is a form of very intense cancer treatment above and beyond “standard” therapy.

Chemotherapy and radiation mostly affect cells that divide rapidly, and cancer cells are the main target because they divide more rapidly than most healthy cells.

However, because normal bone marrow cells also divide rapidly, high-dose chemotherapy and/or radiation can damage or destroy the patient’s own bone marrow. Without healthy bone marrow, the patient can no longer make white blood cells to fight infection, red blood cells to carry oxygen, and platelets to help blood clot.

Both bone marrow transplantation and (peripheral blood) stem cell transplantation place stem cells into the blood after the patient has received high-dose chemotherapy and/or radiation. These new transplanted stem cells travel to the bone marrow to restore the bone marrow’s ability to produce new mature blood cells the patient needs to survive.

SSA instructs that in planning autologous (using own stem cells) bone marrow or stem cell transplantation to support high-dose chemotherapy; it is general practice to treat the individual with one or two cycles of “standard” chemotherapy to check for tumor responsiveness.

A cancer that is totally unresponsive to “standard” chemotherapy is unlikely to successfully respond to autologous bone marrow or stem cell transplantation.

If the therapy plan consists of several cycles of “standard” chemotherapy to be followed by bone marrow or stem cell transplantation, the date of “first treatment” is the date of the first “standard” chemotherapy.

If no “standard” chemotherapy is planned prior to bone marrow or stem cell transplantation, the date of “first treatment” is the date of the transplant.

In my opinion, this approach by SSA regarding the onset of “standard” chemotherapy to set the date of “first treatment” as onset for this listing is fraught with ambiguity and complexity. One could argue for an onset based purely on the point at which the severity of the impairment prevented work, not just when the “standard” therapy began. Though establishing an onset prior to transplantation would probably entail invoking a "less than sedentary RFC" or some other form of medical-vocational allowance.

The listing used to evaluate bone marrow or stem cell transplant depends on the specific malignancy. The criteria in listings 13.05C, 13.06A, 13.06B1, 13.06B2a, 13.07B, 113.05C, 113.06A, 113.06B1, or 113.06B2a do not specify the type of transplant. Only listing 13.28 distinguishes between autologous and allogeneic transplants. SSA evaluates any other malignant neoplastic disease treated with bone marrow or stem cell transplantation under listing 13.28, regardless of whether there is another listing that addresses that impairment.

Bone marrow or stem cell transplantation for aplastic anemia is evaluated under listing 7.17.

Bone marrow or stem cell transplantation for severe auto-immune disorders would be considered as a possible equals under listing 13.28.

Regardless, an individual who has received an autologous bone marrow or stem cell transplant for a malignant neoplastic disease has an impairment that meets a listing.

If the impairment is evaluated under listing 13.28 B, the individual is considered disabled until at least 12 months from the date of the “first treatment” under the treatment plan that involves an autologous transplant.

If the impairment is evaluated under another listing for bone marrow or stem cell transplantation, the individual is disabled until at least 12 months from the date of the transplant.

SSA further instructs that a listing for bone marrow or stem cell transplantation can not be met or medically equaled until the claimant has undergone the transplant. Therefore, if a transplant can not be done because there is no match, or because of funding issues, the listings for bone marrow or stem cell transplantation should not be used to evaluate the claim.

Umbilical cord blood contains large numbers of stem cells; therefore, umbilical cord blood transplants are considered stem cell transplants.